Hallucinations are a fairly common symptom in the advanced stages of Alzheimer’s disease.

Alzheimer’s disease is a progressive neurodegenerative disorder that affects memory, thinking, behavior, and ultimately, a person’s ability to carry out daily activities.

About one-third of people with Alzheimer’s, particularly those in the severe stages, experience dementia-related psychosis. This often includes hallucinations, which can be distressing for both the person experiencing them and their caregivers.

Alzheimer’s hallucinations are false perceptions or sensory experiences that occur in individuals with Alzheimer’s disease. While relatively uncommon in the early stage of the disease, hallucinations become more likely as the disease progresses.

Overall, research suggests that about 30% of people with Alzheimer’s have dementia-related psychosis (hallucinations, delusions).

What are Alzheimer’s hallucinations like?

Visual hallucinations are the most common type of hallucination in Alzheimer’s disease. They often appear with agitation or other mood changes.

Symptoms may include the following:

  • Seeing or interacting with people, animals, or objects that aren’t there: This is the hallmark symptom of visual hallucinations in Alzheimer’s. For example, a person with Alzheimer’s may report seeing their deceased spouse standing in the doorway or describe a nonexistent table or a lamp.
  • Misinterpreting visual stimuli: A person with Alzheimer’s may mistake a jacket on the chair for a dog, or they may misinterpret reflections in mirrors or windows as someone else.
  • Expressing confusion or distress: Individuals may become confused, agitated, or distressed by the hallucinations, as they may not be able to differentiate between what’s real and what’s not.
  • Changes in behavior or mood: Hallucinations in Alzheimer’s may also be accompanied by changes in behavior or mood, such as increased anxiety, fear, or irritation.
  • Possible comorbid delusions: In a study of 1,227 people with probable Alzheimer’s disease, more than one-third of those with visual hallucinations were also experiencing delusions (false beliefs despite undeniable evidence).

The exact cause of hallucinations in Alzheimer’s disease is not fully understood. But they’re likely triggered by the underlying changes occurring in the brain as the disease progresses.

These may include:

  • Brain cell damage: As Alzheimer’s disease progresses, there’s widespread damage to brain cells, including nerve cells and their connections. This can disrupt the regular processing of sensory information, leading to misinterpretation of sensory stimuli and resulting in hallucinations.
  • Cognitive decline: Cognitive decline, including deficits in memory, attention, and perception, can impair an individual’s ability to accurately interpret and make sense of their surroundings. This cognitive impairment may contribute to the development of hallucinations.
  • Neurotransmitter imbalances: The accumulation of abnormal proteins in the brain can disrupt the functioning of nerve cells and neurotransmitters, such as acetylcholine, serotonin, and dopamine. These changes may contribute to the development of hallucinations.
  • Co-existing conditions: People with Alzheimer’s disease may also have other health conditions, such as Lewy body dementia or Parkinson’s disease, which are associated with a higher risk of hallucinations.

At what stage of Alzheimer’s do hallucinations occur?

Hallucinations can occur at any stage of Alzheimer’s disease, but research suggests that they become more common as dementia becomes more severe.

  • Early stage (mild): Hallucinations are less common in the early stage of the disease.
  • Middle stage (moderate): In the moderate stage, individuals may have increasing difficulties with memory, communication, and daily activities. Visual hallucinations may become more frequent during this stage.
  • Late stage (severe): In this stage of Alzheimer’s, individuals often have severe cognitive impairment and require full assistance with daily living activities. Hallucinations may be more severe and involve multiple senses, such as hearing voices or smelling odors that aren’t real.

Supporting a loved one with Alzheimer’s hallucinations can be challenging, but there are several strategies that may help. Here are some tips for providing support:

  • Remain calm and reassuring: It’s important to stay calm and composed when your loved one is experiencing hallucinations. You can say, “I understand that you’re seeing something, but I’m here to help you.”
  • Redirect and distract: During a distressing hallucination, try redirecting your loved one’s attention to a different topic or activity, such as listening to calming music or taking a walk.
  • Provide comfort and companionship: Engage in calming activities, such as holding hands or using comforting words, to help your loved one feel supported and secure.
  • Create a safe environment: Keep the surroundings well-lit and minimize sensory triggers, such as loud noises or bright lights, that may contribute to hallucinations.

How to tell if someone is hallucinating

Here are some signs that your loved one may be experiencing hallucinations:

  • Interacting with nonexistent people or objects: Watch for unusual behaviors, such as your loved one interacting with or talking with people, animals, or objects that aren’t there.
  • Expressing fear or agitation: If a person with Alzheimer’s is displaying signs of extreme distress and is unable to explain why, it may be related to hallucinations.
  • Misinterpreting surroundings: People with Alzheimer’s may perceive objects, people, or places in a way that isn’t consistent with reality. For example, they may mistake a coat rack for a person or perceive the floor as being covered in water.

The treatment of Alzheimer’s hallucinations typically depends on the underlying cause and severity of the hallucinations, as well as the overall health and medical history of the person with Alzheimer’s.

Treatment for Alzheimer’s hallucinations may include the following:

  • Non-pharmacological interventions: Non-drug interventions are usually the first line of treatment for Alzheimer’s hallucinations. These may include creating a calm and safe environment, minimizing sensory triggers, and providing reassurance.
  • Treating underlying medical conditions: It’s important to address any underlying conditions, such as infections, metabolic imbalances, or other health issues, as they can also trigger hallucinations.
  • Medications: In severe cases, antipsychotic medications may be prescribed in limited doses to help manage hallucinations, such as with Nuplazid (pimavanserin). Some research has shown that the effectiveness of antipsychotics may be outweighed by adverse side effects, including further cognitive decline or extrapyramidal symptoms.

Hallucinations generally occur toward the later stages of Alzheimer’s, but this is not always the case. Visual hallucinations are the most common and may look like your loved one interacting with a person or object that isn’t there.

If your loved one is experiencing hallucinations due to Alzheimer’s disease, the best thing you can do is stay calm and focus on keeping your loved one safe and comfortable. Medication may be prescribed to manage hallucinations, but generally, care and support are the first line of treatment.